Provider Demographics
NPI:1760613657
Name:SKINNER, TINA LOUISE (DDS)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LOUISE
Last Name:SKINNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2047 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3279
Mailing Address - Country:US
Mailing Address - Phone:719-566-0206
Mailing Address - Fax:719-561-1095
Practice Address - Street 1:2047 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-3279
Practice Address - Country:US
Practice Address - Phone:719-566-0206
Practice Address - Fax:719-561-1095
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice